An Analysis of Hypertension Patients’ Overlapped Medical Utilization —Using National Health Insurance Registry for Beneficiaries Claims Data Files of 2005

本研究之目的為分析高血壓病人西醫門急診之重複醫療資源利用情形。研究資料以全民健保資料庫2005年承保抽樣歸人檔第一組至第四組共20萬人為基礎，定義國際疾病分類號第一、二、三欄中(主、次診斷碼)任一欄前三碼為401至405之高血壓病人(共20,209名)為研究對象，分析其重複醫療資源利用情形。 分析結果發現重複使用醫療資源者共8,050名，重複使用率為39.83%，重複用藥率為41.62%，用藥日數重複率為2.75%。重複使用醫療資源者中97.81%有重複用藥，重複用藥者平均每人累計重複用藥13.93天，平均每人累計重複藥費為508.46點。重複使用醫療資源者中19.65%有重複使用非藥品醫令，平均每人累計重複非藥品醫令費用為883.06點。有重複使用醫療資源之高血壓病人，平均每人重複的總醫令費用為670.89點，總醫療費用為3,331.19點。 性別方面，女性重複使用醫療資源之機率較男性高，但男性重複使用醫療資源之程度卻較女性高。年齡方面，年齡愈大者愈容易重複使用醫療資源，重複使用的程度也愈高。有重複使用醫療資源者中，免部分負擔者重複使用醫療資源的程度較需部分負擔者高。 病人之C.C.I.越高，會重複使用醫療資源的機率及程度越高，病人因高血壓而看診之醫師數、醫療機構數越多，重複使用醫療資源的機率及程度也越高。 病人的就醫選擇方面，無固定醫療機構權屬別及特約類別者重複使用醫療資源的機率較低，無固定醫療機構權屬別者重複使用醫療資源的程度也較低。論：絕大部分有重複使用醫療資源之高血壓病人有重複用藥。後續研究者可結合問卷，瞭解高血壓病人重複使用醫療資源之原因。The purpose of the study was to analyze hypertension patients’ overlapped medical utilization by using the 2005 National Health Insurance Registry for Beneficiaries Claims Data files, the medical service utilization data of 200,000 persons. This study identified 20,209 hypertension patients visited western outpatient and emergency department. The percentage of overlapped medical resources utilization, overlapped medication and overlapped days of prescriptions was 39.83%, 41.62% and 2.75%, respectively. Among hypertension patients who used overlapped medical resources, 97.81% also had overlapped medication. The average overlapped days of prescriptions and overlapped medication expenses were 13.93 days and 508.46 points. Nineteen point six percent hypertension patients who used overlapped medical resources also had overlapped non-drug orders. The average overlapped non-drug orders expenses were 883.06 points. The average overlapped total orders expenses of 8,050 hypertension patients who used overlapped medical resources were 670.89 points and the overlapped total medical expenses were 3,331.19 points. Females were more likely to use overlapped medical resources, but the degree was lower than males. Hypertension patients’ medical demand and overlapped medical resources utilization increased as age increased. Once the patients used overlapped medical resources, subjects who did not need to pay copayments had higher degree of overlapped medical resources utilization than their counterpart. The probability and the degree of overlapped medical resources utilization were higher when the Charlson comorbidity index was higher. The more the number of doctors and medical facilities patients visited because of hypertension, the higher the probability and the degree of overlapped medical resources utilization. Subjects who did not have a regular place of care were less likely to overlap medical resources utilization than their counterparts and the degree of overlapped medical resources utilization was lower. onclusions: The majority of the hypertension patients who had overlapped medical resources utilization also had overlapped medication. Future researchers can incorporate questionnaire to investigate the reasons of overlapped medical resources utilization.致謝.............................................I文摘要.........................................IIbstract.........................................III一章 前言.....................................1一節 研究緣起................................1 第二節 研究目的...............................2 第三節 研究之重要性...........................2二章 文獻探討.................................3 第一節 高血壓之定義、分類及其臨床治療指引.....3 第二節 國內外高血壓病人之分佈及醫療資源使用情形.. 11 第三節 就醫行為之相關研究.................... 17 第四節 重複醫療資源利用之相關研究.............23 第五節 綜合討論...............................31三章 研究材料與方法...........................34 第一節 名詞定義...............................34 第二節 研究架構...............................38 第三節 研究假說...............................39 第四節 研究對象及材料.........................39 第五節 研究變項...............................39 第六節 資料處理與統計分析.....................43四章 研究結果.................................46 第一節 描述性統計之結果.......................46 第二節 推論性統計之結果.......................48五章 討論.....................................54 第一節 研究結果之討論.........................54 第二節 研究限制...............................61六章 結論與建議...............................62 第一節 結論...................................62 第二節 建議...................................64考文獻.........................................6

A Scleroderma Patient with Sudden Loss of Vision in Both Eyes

Abstract: Scleroderma is a multi-systemic disease. Patients with evidence of major internal organ involvement have increased risks of significant morbidity and mortality. Sudden bilateral painless loss of vision is an uncommon presentation of systemic sclerosis. We reported a case of autoimmune retinopathy in the form of Purtscher's like retinopathy in a scleroderma patient with major internal organ involvement. Keywords: Autoimmune retinopathy, Purtscher's retinopathy, Scleroderma Case History A 49-year-old housewife, with history of treated cutaneous tuberculosis, left hemi-thyroidectomy for thyroid colloid nodules and uterine fibroid, presented to us in June 2007 with symmetrical polyarthralgia, Raynaud's phenomenon, progressive skin thickening over her hands, forearms, legs, trunk, neck and face for six months. She also reported generalized fatigue, shortness of breath on exertion, and occasional acid regurgitation. She did not experience any malar rash, photosensitivity, alopecia, recurrent oral ulcers, sicca symptoms or proximal muscle weakness. Her elder sister has a history of Rheumatoid Arthritis and is on treatment. Physical examination revealed tightening of skin over her hands, forearms, trunk, legs, neck, and face. Raynaud's phenomenon was noted over her fingers with skin cracking of the fingertips. However, no digital gangrene or nail fold infarcts were detected. Prominent synovitis was detected over the small joints of her hands. Fine crepitations were heard over her lung bases. Laboratory investigations revealed a positive anti-nuclear antibody (ANA) at 1:320. Rheumatoid Factor (RF) was negative. Anti-double strended deoxyribonucleic acid (anti-dsDNA) antibody was not elevated. Anti-extractable nuclear antigen (anti-ENA) antibody was negative. Complements C3 and C4 levels were normal. Erythrocyte sedimentation rate (ESR) was elevated at 94 mm/hr. C-reactive protein (CRP) was normal. Lupus anticoagulant was negative. Anti-cardiolipin immunoglobulin G was negative. Baseline Chest X-Ray was unremarkable. X-Ray of her hands and wrists did not demonstrate any bony erosion. Barium swallow showed mild dilatation at mid-esophagus while the mucosal pattern remained unremarkable. Full lung function test revealed a severe diffusion defect as evidenced by a depressed carbon dioxide diffusion capacity (DLCO) as 44% predicted value, and a restrictive total lung volume at 75% predicted. High Resolution Computed Tomography (HRCT) of thorax revealed subpleural linear to reticular shadows compatible with pulmonary fibrosis in the right middle lobe, right lower lobe and left lower lobe. There were no ground glass opacities. Electrocardiography (ECG) and echocardiogram did not show any evidence of pulmonary hypertension. A diagnosis of scleroderma with interstitial lung disease was made. She was given oral diltiazem for relief of Raynaud's phenomenon and oral colchicine for sclerodactyly. Low dose prednisolone 5 mg once daily and cyclosporine A wer

A case of idiopathic inflammatory myopathy complicated by Epstein-Barr virus-associated lymphoma

We report a male patient who had refractory idiopathic inflammatory myopathy (IIM) presented with antisynthetase syndrome, being treated by potent immunosuppressants for years, developed Epstein-Barr virus (EBV)-associated lymphoma. Despite the stepping down of the immunosuppressives and active lymphoma therapy, the patient died. On top of the typical association of IIM and malignancy, rare EBV-associated tumors related to EBV infection secondary to the use of potent immunosuppressive therapies could occur. Further investigations are advisable if there are new symptoms and signs or in refractory IIM cases. This report serves as a diagnostic alert that the causation by EBV infection in unusual tumors found in patients with IIM should be considered, as both the treatment and prognosis may differ. A balance between the risks and benefits of immunosuppressive therapies should always be achieved

A dormant microbial component in the development of pre-eclampsia

Preeclampsia (PE) is a complex, multisystem disorder that remains a leading cause of morbidity and mortality in pregnancy. Four main classes of dysregulation accompany PE and are widely considered to contribute to its severity. These are abnormal trophoblast invasion of the placenta, anti-angiogenic responses, oxidative stress, and inflammation. What is lacking, however, is an explanation of how these themselves are caused. We here develop the unifying idea, and the considerable evidence for it, that the originating cause of PE (and of the four classes of dysregulation) is, in fact, microbial infection, that most such microbes are dormant and hence resist detection by conventional (replication-dependent) microbiology, and that by occasional resuscitation and growth it is they that are responsible for all the observable sequelae, including the continuing, chronic inflammation. In particular, bacterial products such as lipopolysaccharide (LPS), also known as endotoxin, are well known as highly inflammagenic and stimulate an innate (and possibly trained) immune response that exacerbates the inflammation further. The known need of microbes for free iron can explain the iron dysregulation that accompanies PE. We describe the main routes of infection (gut, oral, and urinary tract infection) and the regularly observed presence of microbes in placental and other tissues in PE. Every known proteomic biomarker of “preeclampsia” that we assessed has, in fact, also been shown to be raised in response to infection. An infectious component to PE fulfills the Bradford Hill criteria for ascribing a disease to an environmental cause and suggests a number of treatments, some of which have, in fact, been shown to be successful. PE was classically referred to as endotoxemia or toxemia of pregnancy, and it is ironic that it seems that LPS and other microbial endotoxins really are involved. Overall, the recognition of an infectious component in the etiology of PE mirrors that for ulcers and other diseases that were previously considered to lack one